Provider Demographics
NPI:1457806457
Name:PETERSEN, TYSON DON (DDS)
Entity type:Individual
Prefix:DR
First Name:TYSON
Middle Name:DON
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:763 E 350 S
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84335-1325
Mailing Address - Country:US
Mailing Address - Phone:435-730-6233
Mailing Address - Fax:
Practice Address - Street 1:1260 N 200 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-7560
Practice Address - Country:US
Practice Address - Phone:435-752-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID47741223G0001X
UT10387670-99231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice